Paediatrics is a core element of general practice. I am fortunate to have recently concluded a six-month paediatric rotation as part of my GP ST2 year in a busy city hospital, where I have been able to compare and contrast working with children in secondary care with previous rotations in general practice.
Now, back in primary care, the wealth of experience from which I can draw is giving me confidence in consultations and a new found interest in paediatric problems. Why?
I think perhaps I find it refreshing, the sponge-like nature of a child's brain - when faced with a child's keenness of mind, their ability to see the world as new and shiny, a plaything of discovery - well, yes, I like that simplicity.
I concede they are not uniformly that way, yet even the sullen adolescent with intractable teenager syndrome seems to make me think a little more laterally. I cannot put my finger on it, but as one-fifth of my patient encounters in primary care are with a child, surely it can only be a good thing?
The parallel worlds of the GP surgery and the acute hospital orbit one another as closely in paediatrics as in any other specialty. In both, the consultation is usually triadic as a minimum, with invariably at least one parent involved. Provision has to be made for the terrorisation of one's consulting space, be it a GP's room or a curtained cubicle. Toys are of huge benefit in either setting.
However, differences are also evident. Think of the gravity of the outcome. In primary care, this is likely to be an examination, a prescription, perhaps a follow-up appointment or referral. In hospital, more often it will be a blood test, perhaps IV access or even a lumbar puncture.
Sensitivity in conveying the importance of this acute insult is paramount, as tears are likely to be shed, and just as often by mum or dad as the child. Consultant-led care is the norm in paediatrics, with often seemingly straightforward decisions being made by registrars.
Consequently and reassuringly, a feeling of safety prevails.
A variety of conditions
My rotation allowed me to be involved in many specialised areas not frequently seen in primary care. Assessing and managing neonatal problems, and actually test-feeding babies with suspected pyloric stenosis, or setting up headboxes and CPAP (continuous positive airways pressure) for babies with bronchiolitis helped to consolidate these conditions for me.
Getting close to some of the harsher realities was challenging, but organising transfusions and managing line sepsis in oncology patients has indelibly stamped on my mind the bravery of these incredible children and the challenges they face.
Equally prominent are the babies whose non-accidental injuries were often life-threatening. These tragic tiny bodies, coupled with their case conferences and conversations with social workers, have bestowed upon me the confidence to consider and act swiftly when I encounter such devastating problems in my future career as a GP. Crucially, I now better understand my role in safeguarding children.
Being involved in inpatient and clinic management of children with exacerbations of chronic problems is invaluable for primary care. Seeing children with asthma, cystic fibrosis, autistic spectrum disorder and sickle cell disease during phases of illness and grasping the principles of managing their specific problems enabled me to be better able to place a presentation in primary care more accurately upon their spectrum of wellness.
Managing common GP referrals from within secondary care also consolidates understanding of what actually happens to the children we send to hospital. From feeding regimens for those failing to thrive, to complete septic screens for unwell, pyrexial children and next-step management of conditions we see not infrequently, such as hip pain and proven UTI, these experiences can better inform our care in the GP setting.
Working with secondary care
The interface between GPs and paediatricians need not be as closed as it may seem. Calls went through to the registrar on-call, who was invariably happy to discuss clinical scenarios and offer advice accordingly.
From my ward and clinic experiences, paediatric consultants valued the relationship with their patients and were very amenable to discussing issues with primary care colleagues. I often felt they wished this happened more often.
Much like us as GPs, the relationship with child and family is a highly-prized thing for paediatric staff, and could be optimised for both patient and professional with good communication between generalist and specialist.
Reducing barriers further at a local level is important and there isincreasing role for GPSIs within paediatrics, with acute paediatrics being perhaps the best example; based in the emergency department, children are seen and managed by a GPSI who has direct access to a paediatric registrar available for advice as required.
It is unfortunate that not all GP trainees have the opportunity to undertake a paediatric rotation. For those who do not, attending clinics or consultant rounds would certainly help in better understanding the management and delivery of care to our paediatric patients, and will increase confidence in nurturing children.
- Dr Peter Reeves, a GP ST2 in Coventry, Warwickshire
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